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Membership Application Form
 
About you
Title
Mrs Ms Miss Other
Full name
Address
Postcode
Telephone
Date of birth
   
Please give details of someone we can contact in an emergency
Name & address
Telephone
Relationship to you

Please select the services you require
Central Shopmobility Both

Please complete the following information to help us ensure a safe and comfortable experience
What is the nature of your impairment?
Is this impairment:
Permanent

For Dial-a-Journey customers
Applicants must be unable to use conventional bus services due to a significant mobility impairment.
 
Services you wish to use (tick both if applicable):
Local authority, door-to-door transport services
Other transport services provided by DAJ
 
Are you likely to use any of the following mobility aids?
Manual Wheelchair Walking Frame
Electric Wheelchair Guide Dog
 
Do you have ramped access to your home (If not, please let us know how many steps from your home to ground level (max 3)
Yes No Number of steps:
 
Are you able to travel without assistance?
Yes No    
 
If you hold a national concession scheme card - are you eligible to be accompanied by an assistant (Does your card have C+1 on the front)?
Yes No N/A
 
On joining the Dial-a-Journey scheme, a member of staff may visit you to familiarise you with the scheme. If you do not require a visit, please tick

For Central Shopmobility customers
Approximate weight (It is necessary to ask this question in order that our staff can give you a chair that suits needs. Please tick).
15 - 18 stones 18 - 22 stones Over 22 stones
 
What type of equipment do you usually use?
Manual 3 Wheel Scooter
4 Wheel Power Chair 4 Wheel Scooter
 
Are you trained in the operation of the following?
Manual 3 Wheel Scooter
4 Wheel Power Chair 4 Wheel Scooter

Declaration
 
 
Please tick here to confirm that you agree with the declaration and the statements above:
 
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Order of Malta Dial-a-Journey Ltd, 17 Munro Road, STIRLING FK7 7UU. Charity No. SC 018831. Tel: 01786 465355
Dial a Journey Plus is supported by: Order or Malta | Stirling Council | Falkirk Council | Clackmannanshire Council. Copyright 2009 Dial-a-Journey. All Rights Reserved